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The overlap between traumatic brain injury (TBI) and violence is an important yet little understood problem. The exact number of violence-related TBIs each year is not known. The Centers for Disease Control and Prevention (CDC) estimates that 11% of TBI deaths, hospitalizations, and ED visits combined (a total of 156,000 each year) are related to assaults (Langlois et al, 2004). But this number likely is low because it excludes the many other TBIs, including concussions, caused by violence that go unidentified and unreported. Although not a focus of this article, prisoners and young children are two of the groups at high risk of a violence-related TBI that may not be identified. (See articles by Wald, et al, and Berger, this issue).

Furthermore, the problem of TBI and violence is complicated by the fact that violence is not only a cause, but a consequence of TBI. Specifically,TBI-related cognitive and behavioral problems can also result in aggressive behavior that leads to perpetration of violence, or a lack of insight and judgment, and resulting vulnerability, that can lead to victimization. Depression after TBI can lead to an increased risk of self-inflicted injury, including suicide (Oquendo et al., 2004). Although not a focus of this article, suicide is an important aspect of violence that is addressed elsewhere in this issue (See Brenner article).

The goal of this article is to increase awareness among TBI and health care professionals about the overlap between TBI and violence by summarizing the epidemiology and providing case examples for victimization and aggressive behavior. In addition, we focused on intimate partner violence and TBI because of the limited information published about this topic.

Violence as a Cause of Traumatic Brain Injury

Intimate Partner Violence

The term intimate partner violence (IPV) is also known as domestic violence, spouse abuse, or woman abuse. An “intimate partner” is defined as a current or former partner, including a spouse, boyfriend, or girlfriend (Saltzman et al., 1999). After a relationship ends, many people continue to be at risk for violence from former partners. Intimate partners can be the opposite or the same sex as the victim (Burke et al., 1999; Moracco et al., 2007).

Each year in the United States, women experience about 4.8 million intimate partner-related physical assaults and rapes; men are the victims of about 2.9 million intimate partner violencerelated physical assaults (Tjaden et al., 2000). However, these numbers may underestimate the extent of the problem as certain populations who are more likely to report IPV (prisoners, those living in shelters, transient people, and the homeless) are less likely to be surveyed.

The number of cases of TBI associated with intimate partner violence is not known. However, as mentioned above, CDC estimates that at least 156,000 TBI-related deaths, hospitalizations, and emergency department visits in the U.S. each year are related to assaults (Langlois, et al., 2004). Strangulation or blows to the head may occur in 50 to 90 percent of IPV physical assaults against women (Wolfe et al, 1997; Greenfield et al., 1998). Thus, the true number of violence-related TBIs may be much higher than the CDC estimate. Multiple TBIs, including concussions are frequently reported by incarcerated women with a history of IPV (Pamela Diamond, PhD, University of Texas-Houston, Personal Communication, October 2007).

In one study, 60 percent of the women with IPV-related TBI continued to exhibit TBI-related symptoms 3 months after the injury (Monahan and O’Leary, 1999). Women with TBI frequently exhibit reduced capacity to make informed, consistent choices about whether to leave or return to the perpetrating partner, and their ability to plan and to respond appropriately to safety, health, child care, and parenting issues may be significantly compromised (Monahan and O’Leary, 1999). This increases the likelihood that they will remain in a violent relationship and the risk of sustaining additional injuries, including TBI.

Many victims do not report IPV to police, friends, or family because they think others will not believe them and that the police cannot help (Tjaden et al., 2000).

This may be particularly true for persons with traumatic brain injury (Reichard et al., 2007) for several reasons. First, individuals with TBI are more likely to be dependent on a perpetrator for financial support and physical care. Second, communication problems associated with TBI may make it difficult for victims to report victimization. Third, the perpetrator may claim that the victim should not be taken seriously because of their TBI-related cognitive problems. Finally, victims may not be willing to admit that they have had a TBI because of the fear of negative consequences such as losing custody oftheir children.

Case example

Debra was born in in 1952. She spent 10 years in an abusive relationship with her female partner, and during that time sustained several possible concussions. In 2000, she was lying in bed asleep and was shot several times, including once in the head. She was rushed to the ER and remained in the hospital for 9 days for cranial hemorrhaging. (See sidebar “One Woman’s Story” for a more detailed account)

(Published with permission from Ms. Gray, obtained by the
Alabama Department of Rehabilitation Services)

Violence as a Consequence of TBI

Victimization

A victim is defined as a target of emotional abuse or threatened or actual physical or sexual violence (Saltzman, et al., 2002). Victimization can include physical violence, sexual violence, psychological or emotional abuse, stalking, and neglect.

Persons with disabilities are particularly vulnerable to violence, and their position of vulnerability often makes it more difficult to leave a violent situation. The number of persons with TBI in the U.S. who are victimized each year is not known and existing information regarding the victimization of persons with disabilities has been gleaned from a small number of studies (Marge, 2003). Such studies have shown that persons with disabilities are 4 to 10 times more likely to become a victim of violence, abuse, or neglect than persons without disabilities (Petersilia, 2001). One recent study found that men and women with activity limitations were more likely to experience physical, emotional, and financial abuse, and that women with activity limitations were more likely to experience sexual abuse (Cohen, et al., 2006). Another study found that women with disabilities were 40% more likely to experience intimate partner violence than women without disabilities (Brownridge, 2006).

Research suggests that certain conditions increase the likelihood of violence, abuse or neglect. One study found that violence was more likely among women with a physical disability when they also had more than one disability, a hearing impairment, or were divorced/separated (Milberger, et al., 2003). Another study found that men and women with activity limitations were more likely to report intimate partner violence if they were single, younger, had lower income, and/or had poor health (Cohen, et al., 2006). (For more detailed information about victimization, see the sidebar).

Little is known about the experience of victimization among persons with TBI, however. A recent qualitative research report by Reichard et al. (2007) has begun to shed some light on the problem and provides a number of examples. Selected narratives collected as part of this study are presented below.

Case examples

Victimization of persons with TBIPhysical abuse

I guess because I had on a shirt he didn’t like. I remember it was something about clothes and he threatened to cut the shirt off my body, and I told him he wasn’t cutting the shirt off my body, that I’d go take it off, and then he was going to cut the shirt to shreds, and I told him no, he wasn’t. That I’d take the shirt off but he wasn’t cutting the shirt up, and something about the shirt. He didn’t like the shirt or something, and he had the scissors and he got mad, and I took the scissors away from him, and that’s the only way I’d take off the shirt if he gave me the scissors, and that’s when he pounded me in the head.

Physical and financial abuse

Saturday evening, this fellow [name], who I was going to marry, he tore…he gave me a black eye, he tore up my apartment and demanded a $300 check. [This was not the first time this happened]. He’d hit me and stuff like that. I’ve gone to work with a black eye.

Seeking protection

I went to the police to see what I could do. They told me the temporary restraining order wasn’t worth the paper it was written on. They told me basically it was all a joke. I could get it, but he could show up with a gun and blow me away. That if I was going to do anything, I needed to do it and disappear. I needed to go out of state. I needed to file the papers, go out of state, and then not show up until the day of the court date. That I needed to go ahead and get what I needed done, do it fast, and then leave the state of [state name]. I told them I didn’t have no money. I didn’t have…if I left the state of [state name], how was I going to live? Where was I going to live? How was I going to get there? Due to seizures, I couldn’t drive. I didn’t have no way of driving. What was the deal? And they said they couldn’t help me.

Sexual abuse

I was at a car dealership … getting the car serviced and everything. This elderly man walked in, big smile on, plopped down right next to me, started talking to me very friendly. I started feeling very comfortable with him. Felt like he was like a father figure, you know because my father died when I was…about 5 or 6 years old. Then he started. He put his arm out back behind me. It was a loveseat type thing, which I was feeling very comfortable with him because I was identifying with a father. He started asking questions and so I was talking with him about [the problems he said he was having with his wife and what he could do about them]. And with that he kept getting closer to me… and he moved his hand from the back of the sofa down to the seat and all of a sudden I became aware he was shoving his hand at my butt, up under it and had his thumb stroking my thigh on the outside… my hip area…he was still engaging me in the conversation so that was distracting me…The next thing I know he’s got his hand up my short leg, over into my pubic area, probing, massaging, and I’m looking at him. What are you doing? He said…oh, you’ve just given me the thrill of my life today. And I said remove your hand… I came home rattled…The first thing I did was pick up the phone and I called [name of state] and talked to my friend there and I told him what happened, and I was in hysterics. I mean I was sobbing. I was frantic. I was shaking as I was holding the phone. It’s like I don’t understand why do these things keep happening, you know, and we talked about it and that’s when I first got the insight. He talked to me. He was friendly. You know, he was gentle. He started off appropriate. He kept me distracted, and he was the perfect predator…I’ve been in a situation of no control, … and … distracted, not really able to anticipate where stuff is going. I’m just trying to deal with each moment, so I mean that’s a problem because that means I’m wide open for rape and anything else, and I’ve been fortunate so far no one’s raped me. They’ve molested me, but they have not raped me.

Sexual abuse by a medical professional

It was the second [gynecological exam] in my whole life… [The doctor] dismissed the nurse and he told me to change into a paper gown and he didn’t leave the room….Yeah. And he made me put the thing so it opened in the front…, and then he came over and he pulled the paper open at my breast and everything and he was just looking and his looks were bedroom looks…., and then he took his hands and he started fondling my breasts. After [talking to me about sex and masturbation and touching my private area in a sexual way] … he put [the speculum] in hot and he said I can sterilize you if you ever tell anybody and besides you’ve got a brain injury. They’re not going to believe you.

Violence as a consequence of TBI

Aggressive behavior

According to Silver et al (2005), aggressive behavior after TBI includes explosive behavior that can be set off by minimal provocation and occur without warning. Episodes range in severity from irritability to outbursts that result in damage to property or assaults on others.

Reports of the incidence of aggression vary widely. Studies of patients with TBI conducted in medical outpatient settings typically report low rates of aggressive behavior (Kreutzer et al, 1999). In contrast, persons in a TBI neurobehavioral program displayed an average of about 280 aggressive acts per day during a 14-day period (Alderman et al, 2002). Sexual aggression was reported in 6.5% of a sample of male patients receiving either inpatient or outpatient TBI rehabilitation; the most common offenses were “touching” offenses followed by exhibitionism and overt sexual aggression (Simpson et al., 1999) Increasing evidence suggests that TBI-related aggressive behavior is strongly associated with depression (Kreutzer et al,1996; Tateno et al, 2003; Baguley et al, 2006).

Case examples

Paul was a new 16 year-old driver when he ran his car off the road and both he and his girlfriend sustained TBIs. After a 2 month coma and years of recovery, his social skills have not caught up with his age of 24. He was taken by police to the emergency room when a group of guys beat him severely and took his wallet. Surprised and humiliated, he responded, ”I don’t understand. I just asked them ‘do you want some of this.’ I guess they thought I wanted to fight because they just started beating me up.” Now four years later, despite his best intentions, he loses new friends when he throws things and screams obscenities at them. “They are looking at me and talking too loud” he says. “I said I’m sorry, I go too far before I know it.”

After sustaining a brain injury in Iraq, Steve was diagnosed with post-traumatic stress disorder and depression. One of the effects of his brain injury is that he has a harder time keeping his emotions under control. He blurts out what he’s thinking or flashes his anger. Late one night driving his pickup truck, he and his wife, came to an intersection where he usually turned left. Now there was a ‘No left turn’ sign. Confused, he stopped and tried to figure out what to do. A policeman walked up. According to his wife “The cop, he shines the flashlight right in at Steve, and he’s screaming, ‘Can you not read, stupid?’ and he got irate. Steve said to his wife, ‘This guy just called me stupid.’ He let out the clutch on the truck and yelled at the cop. ‘I’ll show you stupid, because I’m not stupid. It just takes me longer to comprehend.’ ” He wanted to get out of the car then, but his wife told him “No, it’s not worth it.” She calmed him down and the couple drove on. In rehab, Steve is learning strategies to jog his memory and control his anger. He says “I bite my tongue so many times. I–they’ve taught me to really walk off, and it’s a hard thing for me to do, but I’m learning that.”

Reducing the toll of violence after TBI

Victimization

Screening for possible TBI among persons who have experienced intimate partner violence is critical to ensuring that those with TBI-related problems are diagnosed and receive needed services and/or accommodations. Professionals working in IPV prevention can benefit from information and training aimed at helping them identify and manage persons with TBI. Potentially useful methods for screening, identifying and assisting such cases have been proposed by both the Alabama Department of Rehabilitation Services and the Brain Injury Association of Virginia (See Interview with Maria Crowley, this issue, and sidebar of Intimate Partner [Domestic] Violence Resources). Additional research is needed to ensure that the screening methods for identifying TBI are both valid and reliable. The November-December 2007 issue of the Journal of Head Trauma Rehabilitation, which was devoted to articles about screening and identification of TBI, includes information about promising new screening methods.

Similarly, screening for victimization among persons with TBI is also important. Physicians are especially well-placed to conduct such screening. However, recent studies of the screening practices of physicians, including obstetrician–gynecologists, indicate that most conduct screening for violence only when warning signs are observed (Horan et al., 1998; Rodriguez et al., 1999).

Unfortunately, violence can exist in the absence of warning signs in the patient’s behavior or medical history. Women who are victims of violence may not present with symptoms, especially those who experience psychological or emotional abuse. They may conceal what they are experiencing at home. Because of the increased vulnerability of women with disabilities, including those with TBI, it is important to study the utility of screening these patients for IPV.

One of the most widely used screening tools is the Abuse Assessment Screen (McFarlane et al, 1992). This tool is short and has been tested in clinical settings. This and other tools for assessing IPV can be found in the Centers for Disease Control’s publicationIntimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings. [See Intimate Partner (Domestic) Violence Resources sidebar, page 16.]

Aggressive behavior

The need to improve the effectiveness of strategies to manage the anger, aggression, and disinhibition following TBI has been well established (Corrigan and Bach, 2005). The link between TBIrelated behavioral problems and violent victimization described in this article provides an additional reason why work in this area is vitally important. Improvements in behavioral management techniques might yield benefits beyond achieving reductions in problematic behaviors. This could include reduced risks for the forms of victimization that may accompany diminished coping abilities, impulse control problems, and increased irritability.

Conclusion

Violence as both a cause and a consequence of TBI is a serious problem. TBI professionals can play an important role in educating domestic violence workers, health care providers, and other professionals, including those in law enforcement, about ways to better identify and assist persons who experience violence. Additional research is needed to better quantify the extent of the problem and to ensure that screening methods for identifying a history of TBI are valid and reliable.

About the Authors

Jean A. Langlois, ScD, MPH is a senior epidemiologist with the Centers for Disease Control and Prevention. She holds master’s and doctoral degrees in injury epidemiology and health policy from the Johns Hopkins University School of Hygiene and Public Health. Dr. Langlois worked in pediatric traumatic brain injury rehabilitation at the Kennedy Krieger Institute at Johns Hopkins Hospital, and was a Senior Staff Fellow in epidemiology at the National Institute on Aging of the National Institutes of Health before joining the CDC. She has published numerousarticles and reports on traumatic brain injury, and is considered a national expert on the epidemiology of TBI. In 2006, she was the recipient of the Brain Injury Association of Ohio’s Awareness Award, and the North American Brain Injury Society’s Public Policy Award

Jeffrey E. Hall, Ph.D., M.S.P.H. is a behavioral scientist with CDC’s Division of Violence Prevention. He is a medical sociologist whose research has focused on etiologic aspects of youth violence, elder maltreatment, and violence against women.

Matt Breiding, Ph.D. is a behavioral scientist with CDC’s Division of Violence Prevention. He is a psychologist whose research has focused on the topics of intimate partner violence and sexual violence.

Audrey A. Reichard MPH, OTR is an epidemiologist who currently conducts research on occupational injuries at the CDC, National Institute for Occupational Safety and Health, Division of Safety Research. She previously worked in the CDC, National Center for Injury Prevention and Control, Division of Injury Response. Prior to beginning a full-time research position, she practiced as an occupational therapist.

Ms. McDonnell is the Executive Director of the Brain Injury Association of Virginia. She has a Bachelor of Science in Occupational Therapy from the Medical College of Virginia, a postgraduate Certificate in Health Care Management and Administration from Old Dominion University, and a Masters of Public Administration degree from Virginia Commonwealth University (VCU). Anne has over 20 years of experience in brain injury rehabilitation across a continuum of hospital and community based settings, and has worked as a consultant for state agencies and private service providers. She serves on the advisory boards for the VCU and Ohio Valley Center Traumatic Brain Injury Model Systems grants, and holds a clinical faculty position in the School of Occupational Therapy at VCU.

Marlena Wald, MLS, MPH is an epidemiologist at the National Center for Injury Prevention and Control, CDC. She has a strong interest in research on victimization of persons with TBI and is the developer CDC’s fact sheets on this topic and on TBI among prisoners.

Langlois, J.A., Rutland-Brown, W., and Thomas, K.E. (2004) Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Marge K. Introduction to violence and disability. In: Marge K, editor. A call to action: Ending crimes of violence against children and adults with disabilities, a report to the nation. Syracuse: State University of New York, Upstate Medical University; 2003. p. 1-16.

Humans are relatively adaptable beings which is why we are thriving and not dying out like other species. Horrendous disasters such as the Philippines typhoon, the Boxing Day Tsunami, the nuclear disaster in Japan, the major wars of our time, and horrific famines see great suffering, but these events also inspires survival through adaptation. It turns out we possess a strong survival mechanism in our brains directly linked to our bodies, fight, flight, freeze, flop and friend (fffff).

In fact, the survival part of our brain, which is primitive yet effective, is the first to develop in utero starting at around 7 weeks. It regulates our breathing, digestive system, heart rate and temperature, along with the ‘fffff’ system which operates to preserve our life.

If we have to dodge a falling object, jump out of the path of a speeding car, keep very still to avoid being seen, run for the hills from a predator, or get someone potentially threatening ‘onside’ we need this to happen fast. If a baby is scared, cold, hungry, lonely, or in any way overwhelmed this triggers their survival system and they cry to bring an adult to them to help them survive.

If a baby is repeatedly scared and emotionally overwhelmed and they do not get their survival brain soothed, so they can cope, they begin to develop a brain and bodily system which is on hyper alert and the World seems to be a scary place. Sadly, this not something they can ‘just grow out of’. Far from it as what neuroscience is showing us from all the recent findings. An early experience has a profound effect on the way in which a child’s brain forms and operates as the survival brain is on over drive and senses threat everywhere so works too hard, too often, for too long.

Babies and young children systems are flooded with potent stress hormones which help in the event of needing the 5 fffff’s, but they are not good to have at high levels for too long. Imagine the feeling when you truly believe you have lost your wallet with all your cards and money in. You feel a bit faint, your brain is whirring, your heart racing, breathing is shallow, and you may get the urge to empty your bowels or bladder. Hopefully, this may only lasts for the usual 45 minute cycle for those who are not traumatised.

Then stress hormone levels drop and you can think more clearly and resume your day fairly unscathed. What if you are 4, 9 or 15 years old though, how will you cope, especially as your repetitive early childhood trauma of living with domestic violence, unavailable or rough carers, chaos and unpredictability has left you traumatised?

As I referred to at the start, humans are amazingly adaptable in order to survive, although not necessarily thrive. So a child’s system adapts to get whatever basic needs met it can and to live to the next moment, think soldier in a war zone kind of survival. In an abusive environment this will make sense but it is not something a child can just stop doing as their survival brain is in charge and has to do what it has learnt to keep them alive.

The kinds of survival behaviours they commonly develop are:

Regression

Presenting as helpless may have made carers frustrated, even angry and rough with them but will mean they sometimes had to touch a child who presented as unable to say get dressed or wipe their bottom or feed themselves – this can look like immaturity and ‘babyish’ behaviour in an 8 year old but it has previously served a purpose

Being held and touched kindly is a basic human need and tragically children in Romanian orphanages who were not, died. Almost ‘pathetically’ children often devise ways which can seem strange, given their age and previous capabilities, to get some physical contact, even if it’s unpleasant

Children often learn to survive by being ‘like a baby’ as they have either learnt that baby’s get more kindness and attention or have some inbuilt ‘memory’ of this – this can be negatively viewed as regression yet is often an expression of trust in carers as they feel safe enough post abuse to seek out kindness from them so it needs gentle handling and holding until the child is ready to move on. Imagine you had never experienced physical closeness and gentle touch but were driven to seek it out, that takes real courage.

Dramatic reactions

When a child is in the ‘I’ve lost my keys’ panic state most of the day, it’s like a pan boiling on the stove and the smallest extra heat causes it to boil over

The survival brain leaps into action at the slightest thing, an accidental shove from another child, a small scratch on the arm, a lost pencil, a ‘look’ from another child and the 5 fffff’s are triggered, for most children that’s flight but if cornered and unable to escape, or previously over used, it will be fight

Children may cry more readily and for much longer and louder as they do not have the ability to self soothe or to be soothed easily as their brain has not been exposed to this and is not wired that way so telling them to ‘calm down’ is of no use

They are feeling things as deeply as they seem to be at this point and are not just ‘attention seeking’

Disassociation

Disassociation or ‘zoning out’ is another way the brain and body copes with high levels of potentially toxic stress hormones for overly long periods. It can also be a learnt survival strategy, submit, switch off and wait for the frightening, painful, incomprehensible act to be over. This ability to switch off can look like defiance or non-compliance as a child may just stare ahead and not respond to requests from adults

Children cannot continuously cope with the muscle tension, nausea, thudding heart, racing thoughts so finding something to fixate on to soothe them can become a great coping strategy and again will look as if they are being non-compliant whereas they are escaping from their trauma the only way they know how.

How long until they do ‘get over it?’

It’s a fair question as why it’s so hard for traumatised children to trust caring adults. If they were removed from the abuse and trauma as a baby or even directly after birth, surely they should not be having these dramatic reactions?

Going back to our survival part of our brain, this is not designed to be the dominant part of anyone’s brain as we also have an emotional memories part and a thinking, reasoning, socially able cognitive part which should mostly be ‘in charge’. All three areas are interlinked and share info back and forth all the time but mostly we need to think before we act and then we do better. However, if your start in life has made your survival brain ‘hyper alert’ then to manage this is like repeatedly trying to get a squirrel into a matchbox!

Children need us to be calm, kind, to use rhythm, patience and to try to step into their world and emotional state and show empathy.As practitioners it can be helpful to research ways of supporting traumatised children, pushing for appropriate training and most importantly being very aware of the extra strain that comes with working with and caring for traumatised children. However, with the right long term acceptance, kindness and support children can get a better chance at eventually being able to manage their reactive survival brain which has, after all, got them this far.

Some people feel that they are not being abused because they are not being attacked physically. Attempts to control, scare, intimidate and isolate you can be just as damaging to your physical health as physical abuse.

As with other trauma types, children’s responses to domestic violence vary with age and developmental stage. In addition, children’s responses depend on the severity of the violence, their proximity to the violent events, and the responses of their caregivers.

The table below shows a brief list of possible reactions/symptoms by age: young children (birth to age 5), school-age children (aged 6 to 11) and adolescents (aged 12 to 18).

It is important to remember that these symptoms can also be associated with other stressors, traumas, or developmental disturbances, and that they should be considered in the context of the child and family’s functioning.

Children are exposed to or experience domestic violence in many ways. They may hear one parent/caregiver threaten the other, observe a parent who is out of control or reckless with anger, see one parent assault the other, or live with the aftermath of a violent assault. Many children are affected by hearing threats to the safety of their caregiver, regardless of whether it results in physical injury. Children who live with domestic violence are also at increased risk to become direct victims of child abuse. In short, domestic violence poses a serious threat to children’s emotional, psychological, and physical well-being, particularly if the violence is chronic.

Domestic violence poses a serious

threat to children’s emotional,

psychological, and physical well-

being, particularly if the violence is

chronic.

Effects Not all children exposed to violence are affected equally or in the same ways. For many children, exposure to domestic violence may be traumatic, and their reactions are similar to children’s reactions to other traumatic stressors.

Exposure to domestic violence has also been linked to poor school performance. Children who grow up with domestic violence may have impaired ability to concentrate; difficulty in completing school work; and lower scores on measures of verbal, motor, and social skills.

Children may learn that it is

acceptable to exert control or

relieve stress by using violence, or

that violence is linked to

expressions of intimacy and

affection.

In addition to these physical, behavioral, psychological, and cognitive effects, children who have been exposed to domestic violence often learn destructive lessons about the use of violence and power in relationships. Children may learn that it is acceptable to exert control or relieve stress by using violence, or that violence is in some way linked to expressions of intimacy and affection. These lessons can have a powerful negative effect on children in social situations and relationships throughout childhood and in later life.

Is it possible that you are being abused and not even know it? Abuse is not always as obvious as being hit or shoved, called degrading names or cussed out. In fact, it can very well be underhanded or subtle. You may find yourself feeling confused about the relationship, off balance or like you are “walking on eggshells” all the time. This is the kind of abuse that often sneaks up on you as you become more entrenched in the relationship. I am talking here about psychological abuse, which is also known as mental or emotional abuse.

Psychological abuse occurs when a person in the relationship tries to control information available to another person with intent to manipulate that person’s sense of reality or their view of what is acceptable and not acceptable. Psychological abuse often contains strong emotionally manipulative content and threats designed to force the victim to comply with the abuser’s wishes. All abuse takes a severe toll on self-esteem. The abused person starts feeling helpless and possibly even hopeless. In addition, most mental abusers are adept at convincing the victim that the abuse is his/her fault. Somehow, the victim is responsible for what happened.

A more sophisticated form of psychological abuse is often referred to as “gaslighting.” This happens when false information is presented with the intent of making victims doubt their own memory, perception, and sanity. Examples may range simply from the abuser denying that previous abusive incidents ever occurred to staging bizarre events with the intention of confusing the victim. I listened to a client tell me that her husband denied an affair after his she found a racy email to another woman on his computer and confronted him. The husband vehemently denied this and when so far as to send an email to his tech guy asking how his account could have been hacked and to fix the problem!

A common form of emotional abuse is “I love you, but…” That may sound nice at first, yet it is both a disguised criticism and a threat. It indicates, “I love you now, but if you don’t stop this or that, my love will be taken away.” It is a constant jab that slowly strips away your self-esteem. Abusers get a lot of reinforcement out of using the word “love” as it seems to become a magic word to control you.

Abusers at times do what I call “throw you a bone.” I have heard countless times from clients that their partner was “nice,” “complimentary,” “gave me a gift,” etc. as if it should erase all of the bad treatment. You need to understand that this is part of the dynamic and cycle of abuse. In fact, it is rare for abusive relationships to not have these (often intense) moments of feeling good, overly sincere apologies or attempts to make up for the bad behavior. The victim clings to hope when these moments occur and the abuser knows this.

It is important to remember is that it is absolutely not your fault. Abusers are expert manipulators with a knack for getting you to believe that the way you are being treated is your fault. These people know that everyone has insecurities, and they use those insecurities against you. Abusers can convince you that you do not deserve better treatment or that they are treating you this way to “help” you. Some abusers even act quite charming and nice in public so that others have a good impression of them. In private is a different story, which is also quite baffling.

If you see yourself in these words, know that there is little hope for your relationship to improve. It would take a monumental amount of insight and motivation for the abuser to change and unfortunately, this is rarely the case. If you are in an abusive relationship, I urge you to get out and with professional help if needed. Often the first step in leaving the abuser is obtaining counseling just to rebuild your esteem so that you can leave. I particularly want you to know that you may “love” this person, but that they do not “love” you or respect you. I assure you that in time you will get over this person if you break it off. You will be making the right decision…no looking back.

“Every child has the right to live free from violence, but the confronting reality for many children in Australia is that domestic and family violence is a very real part of their everyday lives,” Commissioner Mitchell said.

“This roundtable seeks to better understand the experiences of children exposed to such violence, and to ensure the voices of children are an explicit focus in our broader national conversation about domestic and family violence.”

Prevalence estimates from the 2012 Personal Safety Survey by the Australian Bureau of Statistics also show that children’s exposure to family and domestic violence is widespread in Australia and is predominantly associated with violence against women. According to 2012 estimates, 17% of women and 5% of men in Australia over 15 years had experienced violence by a partner. Much of the violence was seen or heard by children in their care.

“Children and young people have directly raised with me the importance of living free from domestic and family violence,” Commissioner Mitchell said.

“We need to listen to their voices, learn from their experiences and develop the right prevention and reporting measures to keep all children safe.”

The United Nations Committee on the Rights of the Child has previously expressed grave concerns about the exposure of Australian children to family and domestic violence.

“The right of every child to live free from all forms of violence is one of the fundamental principles of the UN Convention on the Rights of the Child,” Commissioner Mitchell said.

“The Convention also requires the protection of children who are exposed to and witness family and domestic violence.

“We as a nation need to do far more to ensure we are meeting our international obligations and are, most importantly, protecting our kids from being subject to violence.”

While there is no national data on the proportion of child protection notifications that relate to family and domestic violence, it is estimated that family and domestic violence is present in 55% of physical abuses and 40% of sexual abuses against children.

The Australian Institute of Health and Welfare has reported during 2013–2014 there were 40,844 substantiated child protection notifications in Australia, with 40% for emotional abuse, 19% for physical abuse and 14% for sexual abuse.

As part of the national consultation, submissions have also been sought from children’s rights experts and community organisations. Findings of the roundtable and national consultation will be the subject of the Children’s Rights Report 2015.